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  • Jefferson Adams
    Jefferson Adams

    Budesonide Effective for Serious Cases of Gluten Exposure

      The team makes clear that they do not advocate steroid use for uncomplicated celiac disease.

    Caption: Image: CC--Jeri Keogel

    Celiac.com 04/16/2019 - A team of researchers from the Celiac Center at Beth Israel Deaconess Medical Center highlighted the potential of an enteric-release, oral budesonide as a treatment for acute reactions to gluten exposure in patients with celiac disease.

    The research team included Amelie Therrien, MD MSc, Jocelyn A. Silvester, MD PhD, Daniel A. Leffler, MD MSc, Ciaran P. Kelly, MD. They are variously affiliated with the Celiac Center, Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston USA; the Celiac Research Program, Harvard Medical School, Boston USA; the Division of Gastroenterology, Hepatology and Nutrition, Boston Children Hospital, Boston USA; the Rady College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada; and with Takeda Pharmaceutical International Co, Cambridge, USA.

    Celiac Center physician, Ciaran Kelly, MD, and colleagues wrote that inadvertent exposure to gluten is still common even though patients specifically try to avoid it.

    Researchers report on a group of consecutive celiac patients with acute gluten exposure, who were treated with enteric-related budesonide. The group included 12 patients with biopsy-confirmed celiac disease, and one patient with potential celiac disease — defined as normal duodenal histology, elevated tissue transglutaminase antibodies, HLADQ2.5 or DG8 positivity and clinical response to a gluten-free diet.

    Researchers measured patient-reported clinical response to budesonide, defined in terms of symptom severity and duration as “substantial,” “partial,” or, simply “response." The patients started budesonide therapy as soon as possible after gluten exposure and symptom onset. All patients reported a clinical response to the drug, with eight patients reporting "substantial" improvement of GI symptoms. 

    The team makes clear that they do not "advocate steroid use for uncomplicated [celiac disease]." The team notes that they selected patients for the budesonide trial based on severe, debilitating gluten reactions, due to intermittent accidental gluten exposure" despite following a [gluten-free diet],” the team wrote. 

    Though the study lacks objective endpoints and includes varying treatments, budesonide can help to relieve serious symptoms of gluten exposures in celiac patients, justifying both this, and future, clinical trials, according to Dr. Alex Young.

    As a disclosure, Dr. Kelley notes that he served as a scientific advisory to Cour Pharmaceuticals, Glutenostics, Innovate, ImmunogenX, and Takeda. He also acts as a principal investigator on research grants on celiac disease supported by Aptalis and Takeda. Please see the full study for all other authors’ relevant financial disclosures.

    Clin Gastroenterol Hepatol 2019. doi:10.1016/j.cgh.2019.03.029.

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  • About Me

    Jefferson Adams earned his B.A. and M.F.A. at Arizona State University, and has authored more than 2,000 articles on celiac disease. His coursework includes studies in biology, anatomy, medicine, science, and advanced research, and scientific methods. He previously served as Health News Examiner for Examiner.com, and devised health and medical content for Sharecare.com. Jefferson has spoken about celiac disease to the media, including an appearance on the KQED radio show Forum, and is the editor of the book "Cereal Killers" by Scott Adams and Ron Hoggan, Ed.D.

  • Related Articles

    Kristen Campbell
    Celiac.com 01/03/2009 - Recently on a gluten-free forum, I found a post asking for advice on what to do after a woman had accidentally consumed a large amount of gluten.  After unknowingly eating from her daughter’s takeout box, the woman had realized her mistake and was simply devastated to have broken her diet and subjected herself to the old, too-familiar symptoms that were on their way.
    It was interesting reading the various responses, which resulted in a debate over whether or not to induce vomiting, drink pineapple juice, take enzymes or engage in a certain illegal activity.  In all the debate, the woman eventually disappeared off the forum, which probably meant that she took some action or another, though I never heard the final result.
    This whole subject inspired some research on my part.  I first consulted my extensive gluten-free library, which led me to one solitary, repetitive answer: do not eat gluten.  In a world where doctors and authors alike are so concerned that their advice on the subject will lead people with gluten sensitivities to forgo a gluten-free diet in favor of a “band aid” of sorts, that finding a documented recommendation is near impossible.
    These experts are right to reinforce the importance of maintaining a gluten free lifestyle, and the fact that there is no “cure” for gluten intolerance and celiac disease (other than complete avoidance of gluten from wheat, barley and rye).  But mistakes do happen, and from time to time people do get "glutened,” and when they do, which action is best?
    No matter what the size is of the offending dose of gluten, all experts agree, inducing vomiting is too dangerous and disruptive to the body to be considered.  But there is one option that at least two noted experts in field of celiac research agree upon: enzymes.
    When I contacted the renowned Dr. Kenneth Fine of EnteroLab, and asked him if perhaps a dose of enzymes that are designed to break down gluten might help, he had this to say: “The good news is that everyone will survive and recover from the gluten exposure.  The enzymes you mention might help, but not completely, unless they consumed at the same time (as the gluten) for best results.”  And like all good doctors, he did go on to warn, “Avoidance is still the best policy.”
    Shari Lieberman, PhD, CNS, FACN and author of The Gluten Connection very humbly admits that “gluten slips happen.”  She also devotes a couple of pages in her book to research conducted using digestive enzymes to help manage those occasions when gluten does make its way into your diet, citing a research example in which “The study demonstrates that enzyme therapy can substantially minimize symptoms in people with celiac disease who are exposed to gluten.” 
    The enzyme used in this study does not seem to be currently available, but other gluten enzymes are at your local health food store.  I contacted one company in regard to their product, which according to them helps to reduce inflammation caused by the introduction of gluten in an individual with celiac disease or gluten intolerance.  According to them their enzymes will not prevent all damage, but may reduce some inflammation and help the body to better digest the protein.
    Ultimately, gluten sensitive individuals should recover from one accidental “gluten slip” here and there, and keeping some digestive enzymes handy to help cope with such an accident is not a bad idea.  But do keep in mind that repeated offenses, even the most minute, will damage your body and prevent it from healing.  Enzymes help treat the symptoms, but only complete avoidance of gluten can treat the disease.


    Jefferson Adams
    Celiac.com 05/19/2014 - A research team recently examined the effects of prednisolone and a gluten-free diet on mucosal epithelial cell regeneration and apoptosis in celiac disease.
    The team included Shalimar, P. Das, V. Sreenivas, S. Datta Gupta, S.K. Panda, and G.K. Makharia. They are with the Department of Gastroenterology and Human Nutrition at the All India Institute of Medical Sciences in Ansari Nagar in New Delhi, India.
    For their pilot randomized, controlled trial, the team looked at thirty-three untreated patients with celiac disease. They randomly assigned 17 of them to a gluten-free diet alone, and the other 16 to a gluten-free diet + prednisolone. Gluten intake was 1 mg/kg for 4 weeks.
    The team conducted duodenal biopsies at the start, and at 4 and 8 weeks following treatment. They recruited six patients with functional dyspepsia as control subjects.
    The team stained all biopsies for markers of intrinsic apoptotic pathway (AIF, H2AX, p53), common apoptotic pathway (CC3, M30), apoptotic inhibitors (XIAP, Bcl2), and epithelial proliferation (Ki-67). They then compared apoptotic (AI) and proliferation indices (PI).
    Initial duodenal biopsies showed the end apoptotic products H2AX and M30 to be markedly higher.
    In comparison with those treated with GFD alone, after 4 weeks of GFD + prednisolone treatment, some markers of both intrinsic and common apoptotic pathways showed rapid decline.
    After prednisolone withdrawal, there was overexpression of H2AX, CC3, and p53 in the latter group. In comparison with those treated with only GFD, patients treated with prednisolone showed suppression of mucosal PI, which started rising again after withdrawal of prednisolone.
    Apoptosis takes place in mucosal epithelium in celiac disease.
    The take away here is that a short course of prednisolone quickly suppresses apoptosis. However, it also suppresses epithelial regeneration, an so should be used only for a short time, if at all.
    Source:
    Dig Dis Sci. 2012 Dec;57(12):3116-25. doi: 10.1007/s10620-012-2294-1. Epub 2012 Jun 30.

    Jefferson Adams
    Celiac.com 07/03/2015 - For people with celiac disease or gluten intolerance, accidentally eating gluten can have numerous undesirable consequences.
    Symptoms of gluten-exposure among people with celiac disease can vary, but main problems and complaints include: upset stomach, stomach pain, inflammation, diarrhea, gas, bloating, indigestion, heart burn, skin rash or breakouts, and nerve and arthritis pain, among others.
    If you're one of these people, then you likely work pretty hard to make sure everything you eat is gluten-free. But what can you do if you accidentally eat gluten?
    Officially, beyond simply waiting it out, there is no clinically accepted treatment for people with celiac disease or gluten sensitivity who accidentally eat gluten. However, there are things that many people claim will reduce the suffering and promote healing when this happens. Here are the best home remedies for accidental gluten ingestion, as submitted by readers to our gluten-free forum.
    The main goal is to reduce or eliminate the worst immediate symptoms, including pain, inflammation, diarrhea, gas and or bloating, etc. The secondary goal is to rebuild gut health.
    So what works? Or, what do people say works for them? The remedies listed below are not ranked in any particular order of importance or efficacy.
    Fasting—Recent studies indicate that fasting for a couple of days can help to reset the immune system, which might be beneficial for those suffering from an adverse gluten reaction. Be sure to check with a doctor before fasting, just to be safe. Digestive Enzymes-- For many people, digestive enzymes seem to help the bloating. Many people claim that such enzymes help provide relief, especially against small amounts of gluten. Two such products are Eater's Digest by Traditional Medicinals, and Gluten Defense digestive enzymes. Green tea or peppermint tea. Many people have reported that green tea is also helpful. Peppermint tea is said to promote muscle relaxation, and can help for gassy stomach issues. Strong gluten-free peppermints will work in a pinch. Imodium seems to help some people control associated diarrhea. If you have diarrhea, be sure to drink water with electrolytes to help replace lost fluids. Pepto-Bismol—Some people take Pepto-Bismol to help relieve stomach upset. Marshmallow root can help to sooth stomach and gas pain. Antihistamines—Some people claim to find relief with antihistamines, such as Benedryl, Clatratin, or Zyrtec. Often these are used in combination with other remedies Probiotics—Many people find probiotics to be helpful, especially as part of a general gut maintenance program. Probiotics are generally more helpful in advance of accidental gluten exposure, but many people take them after exposure. Either way, it certainly can't hurt. Broth—Many people with celiac disease, gut and/or nutritional issues turn to broth for help in building gut health and proper nutrition. Good old fashioned beef, chicken or fish broth can be a beneficial part of a healthy gut regimen. Broth also has many health properties beyond gut healing. Tummy Rescue Smoothie: This recipe was developed by a celiac.com reader in response to his own "gluten emergency.” The healing properties of each ingredient are also listed. Puree in blender until smooth, and slightly thickened. It is most soothing when consumed while still warm from the hot tea. Tummy Rescue Smoothie:
    1 cup hot freshly brewed nettle leaf tea (anti-histamine, anti-spasmodic) ¼ cup Santa-Cruz pear juice (flavoring/sweetener - pears are the least allergenic of fruits) ¼-½ teaspoon whole fennel seed (reduces gas & bloating) 2 Tablespoons slippery elm powder (healing & soothing to mucous membranes and the gut) 1 Tablespoon flax seed oil (soothing, anti-inflammatory) ¼ - ½ cup rice milk (hypoallergenic, use to thin to desired consistency) This smoothie is best consumed in small sips over an hour or so. Magnesium also helps with pain and relaxes muscle spasms, so taking a little extra magnesium may be of benefit. For severe symptoms, drink the smoothie while reclining in bed, with a warm castor oil pack over the abdomen, covered by a heating pad set on low. Do not leave the pack in place for more than an hour.
    Longer-term strategies include rebuilding intestinal health with an anti-inflammatory diet, taking supplements like L-Glutamine, coconut oil, fat-soluble vitamins A, E, D, and K, Calcium, Magnesium, B-Vitamins, Essential Fatty Acids (EFA's), and probiotics, including acidophilus for about a week to get intestinal flora back in order.
    This list is not intended to be authoritative or comprehensive. Nor is it intended as medical advice, or as a substitute for medical advice. As with any health remedy, do your research and make the choices that are right for you.
    If you have any thoughts or insights on how best to treat accidental gluten ingestion for people with celiac disease or gluten intolerance, please share them in our comments section below.

    Jefferson Adams
    Celiac.com 05/24/2017 - Refractory celiac disease (RCD) is a rare manifestation of celiac disease that is difficult to treat, and often results in death from enteropathy-associated T-cell lymphoma.
    Doctors looking to treat RCD have found very limited success with a number of immunosuppressive medications (IMs), including azathioprine, systemic corticosteroids, or regular budesonide. A team of researchers at the Mayo Clinic recently set out to assess open-capsule budesonide (OB) treatment on RCD patients, including those who saw no improvement with previous IM treatments. The research team included Saurabh S Mukewar, Ayush Sharma, Alberto Rubio-Tapia, Tsung-Teh Wu, Bana Jabri and Joseph A Murray.
    The team first looked for RCD patients treated with OB at Mayo Clinic, Rochester, Minnesota from 2003 to 2015. They then reviewed demographic, serologic, and clinical variables in these patients. The team found a total of 57 patients who received OB as treatment for suspected RCD.
    Based on clonal T-cell receptor gamma gene rearrangement or aberrant phenotype of intraepithelial lymphocytes (IELs), the team classified 13 patients (23%) as having RCD-2 and 43 (75%) as RCD-1.
    The team was unable to determine TCR gene rearrangement status for one patient (2%). Most patients were women (69%), with an average age of 60.5 (+/- 3.5) years, while average body mass index was 28.4 kg/m2.
    Nearly 75% of patients suffered from diarrhea, with an average of 6 bowel movements per day (range, 4–25). Nearly half of these patients failed to improve with IM treatment. Twenty-four patients (42%) were anemic, while 12 patients (21%) had hypoalbuminemia. Biopsies showed Marsh 3 lesions in all patients, broken down as follows: 19% were Marsh 3a, 46% were Marsh 3b, and 35% were Marsh 3c.
    After OB therapy, 92% showed clinical improvement, while 89% showed histologic improvement. Subsequent biopsies showed that 7 out of 13 patients with RCD-2 (53%) displayed an absence of the previously observed clonal TCR gamma gene rearrangement/aberrant IEL phenotype. During the follow-up period, two patients died of enteropathy-associated T-cell lymphoma.
    Most RCD patients show clinical and histopathologic improvement with OB treatment, including those who previously failed to respond to other IMs.
    These results show that treatment with open-capsule budesonide is a promising option for patients looking to manage RCD.
    Source:
    The American Journal of Gastroenterology, (21 March 2017). doi:10.1038/ajg.2017.71

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